38 C. H. Ralfe, Seamen's Hospital, London: see Aitken's Handbook of Treatment, New York, 1882, p. 116.
When the advance is toward a fatal issue the emaciation progresses until it becomes extreme; nothing but skin and bone are left. The cuticle is hard and dry, pale or brownish in color. The muscular strength is so reduced that the patient is unable to move from bed. The voice may sink to a whisper. The nervous depression and moroseness assumes a more marked character. Among the soldiers during the Civil War who had undergone great privations with insufficient or improper diet the mental phenomena were those of dementia.39 In them the disease was modified also by the symptoms of scurvy and malarial poisoning.
39 W. Kempler, "Entero-Colitis," Am. Journ. of Med. Sci., vol. lii., 1866, p. 337.
Fever is seen in the late stages; it is nocturnal at first, and later assumes the features of hectic. The pulse grows more frequent and thready; aphthous deposits appear on the inside of the mouth and pharynx. Toward the end the discharges may become more frequent and very abundant; they are more fluid, lighter colored or black, with floating particles of blood and mucus. There may be a loss of odor or they may have a cadaveric smell.
Death takes place in a few weeks or after years of alternate suffering and relief. The immediate causes of death are exhaustion, marasmus from starvation, collapse from perforation of an intestinal ulcer and consecutive peritonitis, syncope from sudden exertion, pneumonia, or acute pulmonary congestion, pleurisy, or subarachnoid effusion in the brain, with coma and convulsions.
COMPLICATIONS.—General dropsy results from the hydræmia and languid circulation of the late period of the disease. Other causes of this symptom are coincident diseases of the liver, kidney, or the malarial cachexia. Oedema of one extremity follows a thrombus in the crural vein. Chronic bronchitis and pulmonary phthisis are sometimes met with. Acute pneumonia40 and acute pulmonary congestion are occasional causes of death. Peritonitis may occur with and without perforation. The latter variety begins as a local inflammation of subacute or chronic nature, and spreads slowly until it becomes general. Extensive adhesions and abundant accumulations of serous, sero-purulent, or purulent fluid in the abdominal cavity result.
40 Pneumonia (8 double and 12 single) occurred in 20 out of 41 fatal cases reported by Harrison Allen, Tr. Path. Soc. Philada., 1867, vol. ii. p. 161.
The causal conditions which have been enumerated may be considered as complications. They are tuberculosis, Bright's disease, cirrhosis of the liver, abdominal tumors, scurvy, tubercular and other neoplasms in the wall of the intestine; attacks of intercurrent, intermittent, or remittent fever arise from the malarial influence to which the intestinal catarrh is due. These fevers and rheumatism and pseudo-rheumatism are complications in soldiers from the exposure to malarial influences and to cold and dampness.41
41 Woodward, op. cit., p. 495.
Ulceration of the cornea, escape of the aqueous humor, and collapse of the eye were observed in quite a number of cases occurring among soldiers.42